Measurementof Joint MotionA Guide to Goniometry

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Cynthia C. Norkin, EdO, PTFormer Associate Professor and DIrector School of Physical Therapy , (,;}!;C~ilege of Health and Human Services ,?!ic)hioUniversity j'Athens, Ohio

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,:V,;, ,d. joyce White,

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;ro, A~sociate Professor of Physical TherapyCollege of Health Professions University of Massachusens Lowell Lowell, Massachusetts

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Measurement of Joint MotionA Guide to GoniometryTHIRD EDITIONPhotographs by Jocelyn Greene Molleur and Lucia Grochowska Littlefield Illustrations by Timothy Wayne Malone Additional illustrations provided by Jennifer Daniell and Meredith Taylor Stelling

+

F. A. Dovl' Comp,ny Phil,d"phi.

FIRST INDIAN EDITION 2004

2003 by F.A. Davis Company

84-5

ThiS:.,edltionhas be;en,published in India by arrangement with F.A. Davis Company, 1915 Arch:.:Slreel, Philadelphia, PA 10103. All rights reserved. No part of this publication may be .reproduced, slored in a retrieval system. or transmitted in any form or by any means, elect~onic, mechanical, photocopying, recording or otherwise, without prior written permission from the publisher.

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in I~~ia.

Pakistan, Bangladesh, Burma, Bhutan and Nepal only.

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To Alexandra, Taylor, and Kimberly.

CCNTo Jonathan, Alexander, and Ethan. DJW

The measurement of joint motion is an important component of a thorough physical examination of the extremities and spine, one which helps health professionals identify impairments and assess rehabilitative status. The need for a comprehensive text with sufficient written detail and photographs to allow for the standardization of goniometric measurement methods-both for the purposes of teaching and clinical practice led to the development of the first edition of the Measurement of Joint Motion: A Cuide to Coniometry in 1985. Our approach included a discussion and illustration of testing position, stabilization, end-feel, and goniometer alignment for each measurable joint in the body. The resulting text was extremely well received by a variety of health professional educational programs and was used as a reference in many cl!nical settings. In the years following inirial publication, a considerable amount of research on the measurement of joint motion appeared in the literature. Consequently, in the second edition, which was published in 1995, we created a new chapter on the reliability and validity of joint measurement and added joint-specific research sections to existing chapters. We also expanded the text by adding structure, osteokinematics, arthrokinematics, capsular and noncapsular patterns of limitation, and functional ranges of motion for each joint. The expanded third edition includes new research findings to help clarify normative range of motion values for various age and gender groups, as well as the range of motion needed to perform common functional tasks. We added current information on the effects of subject characteristics, such as body mass, occupational and recreational activities, and the effects of the testing process, such as the testing position and type of measuring instrument, on range of motion. New to the third edition is the inclusion of muscle length testing at joints where muscle length is often a factor affecting range of motion. This addition integrates the measurement proce>lures used in this book with the American Physical Therapy Association's Cuide to Physical Therapy Practice. Inclinometer techniques for measuring range of

motion of the spine are also added to coincide with current practice in some clinical settings. We introduce illustrations to accompany anatomical descriptions so that the reader will have a visual reminder of the joint structures involved in range of motion. New illustrations of bony anatomical landmarks and photographs of surface anatomy will help the reader align the goniometer accurately. In addition, over 180 new photographs replace many of the older, dated photographs. Similar to earlier editions, the book presents goniometry logically and clearly. Chapter 1 discusses basic concepts regarding the use of goniometry to assess range of motion and muscle length in patient evaluation. Arrhrokinematic and osteokinematic movements, elements of active and passive range of motion, hypomobility, hypermobility, and factors affecting joint motion are included. The inclusion of end-feels and capsular and noncapsular patterns of joint limitation introduces readers to current concepts in orthopedic manual therapy and encourages them to consider joint structure while measuring joint motion. Chapter 2 takes the reader through a step-by-step process to master the techniques of goniometric evaluation, including: positioning, stabilization, instruments used for measurement, goniometer alignment, and the recording of results. Exercises that help develop necessary psychomotor skills and demonstrate direct application of theoretical concepts facilitate learning. Chapter 3 discusses the validity and reliability of measurement. The results of validity and reliability studies on the measurement of joint motion are summarized to help the reader focus on ways of improving and interpreting goniometric measurements. Mathematical methods of evaluating reliability are shown along with examples and exercises so that the readers can assess their reliability in taking measurements. Chapters 4 to 13 present detailed information on goniometric testing procedures for the upper and lower extremities, spine, and temporomandibular joint. When appropriate, muscle length testing procedures are also included. The text presents the anatomical lanIUlllar""

viii

PREFACE

testing position, stabilization, testing motion, normal end-

We hope this book makes the reaching and learning ofgoniometey easier and improves the standardization and

feel, and goniometer alignment for each joint and motion,in a format that reinforces a consistent approach to eval-

uation. The exrensive use of photographs and caprions eliminares the need for repeated demonstrations by aninstruc(Qc and provides the reader with a permanent

reference for visualizing rhe procedures. Also included is information on joint structure, osteokinematic and arrhrokinematic motion, and capsular patterns of restrictions. A review of current literature regarding normal range of motion values; rhe effecrs of age, gende~ and other factors; funcrional range of motion; and reliability and validity is also presented for each body region ro assisr rhe reader to comply with evidence-based practice.

thus rhe reliabiliry of rhis assessmenr tool. We believe thar the rhird edirion provides a comprehensive coverage of rhe measurement of joint marion and muscle length. We hope thar rhe addirions will morivate healrh professionals (0 conduct research and to use research results in evaluation. We encourage our readers to provide us with feedback on our currenr efforts ro bring you a highquality, user-friendly rext.

CCNDJW

We are very grateful for the contributions of the many people who were involved in the development and production of this text, Photographer Jocelyn Molleur applied her skill and patience during many sessions at the physical therapy laboratory at the Universiry of Massachusetts Lowell to produce the high-qualiry photographs that appear in this third edition. Her efforts combined with those of Lucia Grochowska Littlefield, who took the photographs for the fitst edition, are responsible for an important featute of the book. Timothy Malone, an artist from Ohio, used his talents, knowledge of anatomy, and good humor to create the excellent illustrations that appear in this edition. We also offer OUt thanks to Jessica Bouffard, Alexander White, and Claudia Van Bibber who graciously agreed to be subjects for some of the photographs. We wish to exptess our appreciation to these dedicated professionals at F. A Davis: Margaret Biblis,

Publisher, and Susan Rhynet, Manager of Creative Development, for their encouragement, ingenuity, and commitment to excellence. Thanks are also extended to Sam Rondinelli, Production Manager; Jack Brandt, Illustration Specialist; Louis Forgione, Design Manager; Ona Kosmos, Editorial Associate; Melissa Reed, Developmental Associate; Anne Seitz, Freelance Editot; and Jean-Francois Vilain, Former Publisher, We are grateful to the numetous students, faculry, and clinicians who over the years have used the book Ot formally reviewed portions of the manuscript and offered insightful comments and helpful suggestions. Finally, we wish to thank our families: Cynthia's daughter, Alexandta, and Joyce's husband, Jonathan, and sons, Alexander and Ethan, fot their encouragement,support, and tolerance of "time away" for this endeavor.

We will always be appteciative.

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Suzanne Robben Brown, MPH, PT Associate Professor & Chair Department of Physical Therapy Arizona School of Health Sciences Mesa, AZ Larty Chinnock, PT, EdD Instructor!Academic Coordinator Department of Physical Therapy Lorna Linda University School of Allied Health Professions Lorna Linda, CA Robyn Colleen Davies, BHSCPT, MAPPSC, PTLecturer

Deidre Lever-Dunn, PhD, ATCAssistant Professor

Department of Health SciencesProgram Director

Athletic Training Education University of Alabama Tuscaloosa, AL John T. Myers, PT, MBA InstrucrorlProgram Director Physical Therapy Assistant Program Lorain County Community College Elyria,OH James R. Roush, PhD, PT, ATC Associate Professor Department of Physical Therapy Arizona School of Healrh Science Mesa, AZ Sharon D. Yap, PTA, BPS Academic Coordinator of Clinical Education Physical Therapy Assistant Program Indian River Community College Fort Pierce, FL

Department of Physical Therapy University of TorontoToronto, Canada

Jodi Gootkin, PT Site Coordinator Physical Therapy Assistant Program Broward Community College Ft. Myers, FL

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PART I

Introduction to GoniometryCHAPTER 1

13

EXERCISE 4: Explanation of Gonlometry EXERCISE 5: Testing Procedure for Gonlometrlc Evaluation of Elbow Flexion

Basic ConceptsGONIOMETRY JOINT MOTION Arthrokinematics Osteokinematics RANGE OF MOTION Active Range of Motion Passive Range of Motion Hypomobility Hypermobility Factors Affecting Range of Motion MUSCLE LENGTH TESTING

CHAPTER 3

Validity and ReliabilityVALIDITY Face Validity Content Validity Criterion-related Validity Construct Validity RELIABILITY Summary of Goniometric Reliability Studies Statistical Methods of Evaluating Measurement Reliability Exercises to Evaluate Reliability EXERCISE 6: Intratester Reliability EXERCISE 7: Intertester Reliability

39

CHAPTER 2

ProceduresPOSITIONING STABILIZATION EXERCISE 1: Determining the End of the Range of Motion and End-feel MEASUREMENT INSTRUMENTS Universal Goniometer Gravity-dependent Goniometers (Inclinometers) Electrogoniometers Visual Estimation EXERCISE 2: The Universal Goniometer ALIGNMENT EXERCISE 3: Goniometer Alignment for Elbow Flexion RECORDING Numerical Tables Pictorial Charts Sagittal-frontal-transverse-rotation Method American Medical Association Guide to Evaluation Method PROCEDURES Explanation Procedure Testing Procedure

17 PART II

Upper-Extremity TestingCHAPTER 4

5557

The ShoulderSTRUCTURE AND FUNCTION Glenohumeral Joint Sternoclavicular Joint Acromioclavicular Joint Scalpulothoracic Joint RESEARCH FINDINGS Effects of Age, Gender, and Other Factors Functional Range of Motion Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: THE SHOULDER LANDMARKS FOR GONIOMETER ALIGNMENT Flexion Extension

xiv

CON TEN T S

Abduction Adduction Medial (Internal) Rotation Lateral (External) Rotation

CHAPTER 5

The Elbow and Forearm

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STRUCTURE AND FUNCTION Humeroulnar and Humeroradial Joints Superior and Inferior Radioulnar Joints RESEARCH FINDINGS Effects of Age, Gender, and Other Factors Functional Range of Motion Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: ELBOW AND FOREARM LANDMARKS FOR GONIOMETER ALIGNMENT Flexion Extension Pronation Supination MUSCLE LENGTH TESTING PROCEDURES: ELBOW AND FOREARM Biceps Brachii

Triceps Brachii

RESEARCH FINDINGS Effects of Age, Gender, and Other Factors Functional Range of Motion Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: FINGERS LANDMARKS FOR GONIOMETER ALIGNMENT Metacarpophalangeal Flexion Metacarpophalangeal Extension Metacarpophalangeal Abduction Metacarpophalangeal Adduction Proximal Interphalangeal Flexion Proximal Interphalangeal Extension Distal Interphalangeal Flexion Distal Interphalangeal Extension RANGE OF MOTION TESTING PROCEDURES: THUMB LANDMARKS FOR GONIOMETER ALIGNMENT Carpometacarpal Flexion Carpometacarpal Extension Carpometacarpal Abduction Carpometacarpal Adduction Carpometacarpal Opposition Metacarpophalangeal Flexion Metacarpophalangeal Extension Interphalangeal Flexion Interphalangeal Extension MUSCLE LENGTH TESTING PROCEDURES: FINGERS Lumbricals, Palmar and Dorsal Interossei

CHAPTER 6

The WristSTRUCTURE AND FUNCTION Radiocarpal and Midcarpal Joints RESEARCH FINDINGS Effects of Age, Gender, and Other Factors Functional Range of Motion Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: WRIST LANDMARKS FOR GONIOMETRIC ALIGNMENT: THE WRIST Flexion Extension Radial Deviation Ulnar Deviation MUSCLE LENGTH TESTING PROCEDURES: WRIST Flexor Digitorum Profundus and Flexor Digitorum Superficialis Extensor Digitorum, Extensor Indicis, and Extensor Digiti Minimi

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PART III

Lower-Extremity TestingCHAPTER 8

181183

I

The Hip

CHAPTER 7

The HandSTRUCTURE AND FUNCTION Fingers: Metacarpophalangeal joints Fingers: Proximal Interphalangeal and Distal Interphalangeal Joints Thumb: Carpometacarpal Joint Thumb: Metacarpophalangeal joint Thumb: Interphalangeal Joint

137

STRUCTURE AND FUNCTION Iliofemoral joint RESEARCH FINDINGS Effects of Age, Gender, and Other Factors Functional Range of Motion Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: HIP LANDMARKS FOR GONIOMETER ALIGNMENT Flexion Extension Abduction Adduction Medial (Internal) Rotation Lateral (External) Rotation MUSCLE LENGTH TESTING PROCEDURES Hip Flexors (Thomas Test) The Hamstrings: Semitendinous, Semimembranosus, and Biceps Femoris (Straight Leg Test) Tensor Fascia Latae (Ober Test)

CHAPTER 9

The KneeSTRUCTURE AND FUNCTION Tibiofemoral and Patellofemoral Joints

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CONTENTS

xv

RESEARCH FINDINGS Effects of Age, Gender, and Other Factors

PART IV

Functional Range of MotionReliability and Validity RANGE OF MOTION TESTING PROCEDURES: KNEE LANDMARKS FOR GONIOMETER ALIGNMENT Flexion

Testing of the Spine and Temporomandibular JointCHAPTER 11

293" ""."..295

ExtensionMUSCLE LENGTH TESTING PROCEDURES: KNEE Rectus Femoris: Ely Test

The Cervical Spine """"."

Hamstring Muscles: Semitendinosus, Semimembranosus,and Biceps Femoris: Distal Hamstring Length Test

CHAPTER 10

The Ankle and Foot

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241

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STRUCTURE AND FUNCTION Proximal and Distal Tibiofibular joints Talocrural joint Subtalar joint Transverse Tarsal (Midtarsal) joint Tarsometatarsal joints Metatarsophalangeal Joints Interphalangeal Joints RESEARCH FINDINGS Effects of Age, Gender, and Other Factors Functional Range of Motion Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: ANKLE AND FOOT LANDMARKS FOR GONIOMETER ALIGNMENT: TALOCRURAL JOINT Dorsiflexion: Talocrural joint Plantarflexion: Talocrural joint LANDMARKS FOR GONIOMETER ALIGNMENT: TARSAL JOINTS Inversion: Tarsal Joints

STRUCTURE AND FUNCTION Atlanto-occipital and Atlantoaxial Joints Intervertebral and Zygapophyseal joints RESEARCH FINDINGS Effects of Age, Gender, and Other Factors Functional Range of Motion Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: CERVICAL SPINE LANDMARKS FOR GONIOMETER ALIGNMENT

FlexionExtension Lateral Flexion

Rotation

CHAPTER 12

The Thoracic and Lumbar Spine ""." .. ".331STRUCTURE AND FUNCTiON Thoracic Spine Lumbar Spine RESEARCH FINDINGS Effects of Age, Gender, and Other Factors

Functional Range of MotionReliability and Validity RANGE OF MOTION TESTING PROCEDURES ANATOMICAL LANDMARKS: FOR TAPE MEASURE ALIGNMENT Thoracic and Lumbar Flexion

Eversion: Tarsal JointsLANDMARKS FOR GONIOMETER ALIGNMENT: SUBTALAR JOINT (REARFOOn Inversion: Subtalar Joint (Rearfoot) Eversion: Subtalar Joint (Rearfoot)

lumbar FlexionThoracic and Lumbar ExtensionLumbar Extension Thoracic and Lumbar Lateral Flexion Thoracic and Lumbar Rotation

Inversion: Transverse Tarsal Joint

Eversion: Transverse Tarsal JointLANDMARKS FOR GONIOMETER ALIGNMENT: METATARSOPHALANGEAL JOINT Flexion: Metatarsophalangeal joint Extension: Metatarsophalangeal joint Abduction: Metatarsophalangeal joint Adduction and Metatarsophalangeal joint Flexion: Interphalangeal joint of the First Toe and Proximal Interphalangeal joints of the Four Lesser Toes Extension: Interphalangeal joint 'of the First Toe and Proximal Interphalangeal joints of the Four Lesser Toes Flexion: Distal Interphalangeal joints of the Four Lesser Toes Extension: Distal Interphalangeal Joints of the Four

CHAPTER 13

The Temporomandibular JointSTRUCTURE AND FUNCTION Temporomandibular Joint RESEARCH FINDINGS Effects of Age, Gender, and Other Factors Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: TEMPOROMANDIBULAR JOINT LANDMARKS FOR RULER ALIGNMENT MEASURING Depression of the Mandible (Mouth Opening) Protrusion of the Mandible Lateral Deviation of the Mandible

365

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Lesser ToesMUSCLE LENGTH TESTING PROCEDURES:

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xvi

CONTENTS

APPENDIX A

APPENDIX C

Normative Range of Motion ValuesAPPENDIX B

Goniometer Price Lists .375APPENDIX D

383

Joint Measurements by Body Position

381

Numerical Recording Forms Index

387 393

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87,93

Introduction to GoniometryObjectivesON COMPLETION OF PART 1 THE READER WILL BE ABLE TO:

1. Define:goniomerry planes and axes range of motion end-feel mllscle length testing reliability validity 2. Identify the appropriate planes and axes for each of the following motions: tlexion-extcnsion, abduction-adduction, and rotation

5. Describe the parts of universal, fluid, and pendulum goniomctcrs 6. List: the six-step explannrion sequence rhe 12-srcp testing sequence rhe 10 items included in recording

7. Perform a goniomcrric evaluation of theelbow joint including: a clear explanation of rhe procedure positioning of a subject in the testing position adequate stabilization of the proximal joint componenr a corn;ct determination oJ the end of the rangeof motion

3. Compare:active and passive ranges of motion arrhrokinematic and osteokinematic motions soit, iirm, and hard end-feels hypomobiliry and hypermobility capsular and noncapsular pan:erns of rcsrricred motion one, two-, and multijoinr muscles rcliabiliry and validiry intratesrer and- intcrrestcr .re[jab.ili[~1 .; 4. Explain the importance of: resting positions stabilization clinical estimates of range of motion recording st~1rting and ending positions

a correct identification of the end-feci palpation of the correcr bony landmarks accurate alignmclH of rhe goniometer carn::C reading of the goniometer and recording of the measurement

8. Perform and interpret intratestcr andimertcstcr reliability tests including standard deviation, coefficient of variation, correlation coefficients, and standard crror of mcasurement.

Basic ConceptsThis book is designed to serve as a guide to learning the technique of human joint measutement called goniometry,. Background information on principles and procedures necessary for an understanding of goniometry is found in Part 1. Ptactice exercises are included at approptiate intervals to help the examiner apply this information and develop the psychomotor skills necessary for competency in goniometry, Procedures for the goniometric examination of joints and muscle length testing of the upper extremity, lower extremity, and spine and temporomandibular joint are presented in Parts 2, 3, and 4, respectively,

I

Therefore, goniometry refers to the. measurement of angles, inJ'art~cular the meas.urement of angles cteated."!.human joints by the bones of the body, The examiner obtains these measurements by placing the parts of the measuring instrument, called a goniometer, along the bones immediately proximal and distal to the joint being evaluated, Goniometry may be used to determine both a particular joint position and the total amount of motion available at a joint,

Goniometry

The term gQlliometry is derived from two Greek wordS h gonia, meaning angle, a~~~,,~!J...tQ!h., meaning measure.

FIGURE I-I The upper leftextremity of a subject in the supine position is shown. The pans of the measuring instrument have been placed along

the proximal (humerus) anddistal (radius) components and centered over the axis of

the elbow joint, When thedistal component has been moved toward the proximal component (elbow flexion), a measurement of the arc of motion can be obtained.

3

r4PART I INTRODUCTION TO GONIOMETRY

Goniometey is an important part of a comprehensive examination of joints and surrounding soft tissue. Acomprehensive examination typically begins by inter-

viewing the subject and reviewing records to obtain an accurate description of current symptoms; functional abilities; occupational, social and recreational activities;and medical history. Observation of the body to assess bone and sofr tissue contour, as well as skin and nail condition, usually follows the interview. Gentle palpation is used to determine skin temperature and the quality of soft tissue deformities and to locate pain symptoms in

(glides). spins, ond rolls.' A slide (glide), which is a trans!awr)' motion, is the sliding of one joint surface Over anmher, as \vhcn a braked wheel skids. A spin is a rotary (3ngular) motion, similar ro the spinning of a toy top. All points on the moving joim surface rotate at a constant disrance around a fixed axis of motion. A roll is a rotary motion similar to the rolling of the bottom of a rocking chair on the floor, or the rolling of a tirc on the road. In the human body, glides, spins, and rolls Llsually Occur in combination \vith each other and result in movement of the shafts of the bOI1('s.

rdation to anatomical structures. Anthropometric measurements such as leg length, circumference, and body volume may be indica red. The performance of acrive joint motions by the subject during the examinacion allows the examiner to screen for

OsteokinematicsOstcokincmatics refers to the movement of the shafts of bones father than the movemcnt of joint surfaces. The movements of the shafts of borll'S are usually described in terms of the rorary mOtion produced. as if the movement o~curs around a fixed axis of motion. Goniomctr} meaSlIfC:'S the angles created by the rotary morion of the shafts of the bones. However, some translatory motion usually accompanies rotary motion and creates a slightly changing . l xis of motion during movement. Ncverrheless, most clinicians find the description of osreokilH.:matic movell1em in terms of rotary motion sufficiently accurate and lise goniometry ro measure osrcokincmatic movcments.

abnormal movements and gain information about the subject's willingness to move. If abnormal active motions 3rc found, the examiner performs passive joint motions in an attempt co determine reasons for joint limitation.Performing passive joint motions enables the examiner to assess the tissue that is limiting the motion, detect pain, and make an estimate of the amount of motion. Goniometry is used to measure and document the amount of active and passive joint motion as well as abnormal fixed joint positions. Resisted isometric muscle contractions, joint integrity and mobility tests, and special tests for specific body regions are used in conjunction with goniometty to help identify the injured anatomical structures. Tests to assess muscle performance and neurological function are often included. Diagnostic imaging procedures and laborarory tests may be required. Goniometric data used in conjunction with other information can provide a basis for: Determining the presence or absence of impairment Establishing a diagnosis Developing a prognosis, treatment goals, and plan of care Evaluating progress or lack of progress roward rehabilitarive goals Modifying treatment Motivating the subject Researching the effectiveness of therapeutic techniques or regimens; for example, exercises, medications, and surgical procedures Fabricating orthoses and adaprive equipment

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Planes and Axes

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Joint Motion

ArthrokinematicsMotion at a joint occurs as the result of movement of one joint surface in relation to another. Arthrokinematics is the term used to refer to the movement of joint surfaces. The movements of joint surfaces are described as slides

Osteokinematic mOtions arc classically described as taking place in one of the three cardinal planes of the bod)" (sagittal, fromal, transverse) around three corre- '" sponding axes {medial-lateral, anterior-posterior, verticol). The three planes lie at right angles to one another, 1 whereas the three axes lic at right angles both to one fanother and to their corresponding planes. , The sagirral plane proceeds from the amerior to the posterior aspect of the body. The median sagittal plane divides the body into right and left halves. The motions of flexion and extension occur in the sagirral plane (Fig. 1-2). The axis around which the motions of flexion and extension occur may be envisioned as a line that is perpendicular to the sagittal plane and proceeds from one side of the body to the other. This axis is called a medial-lateral axis. All mOtions in the sagittal plane take place around a medial-lateral axis. The fro mal plone proceeds from one side of thc body to the other and divides the body into from and back halves. The motions that occur in the frontal plane are abduction and adduction (Fig. 1-3). Thc axis around which the motions of abduction and adduction take place is an amerior-posterior axis. This axis lies at right angles ro the fromal plane and proceeds from the amerior to the posterior aspect of the body. Therefore, the anterior-posterior axis lies in the sagittal plane. The transverse plane is horizontal and divides the body into upper and lower portions. The motion of rota-

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CHAPTER 1

BASIC CONCEPTS

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MediaHateral axis

Anterior - posterior axis

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FIGURE 1-2 The shaded areas indicate the sagittal plane. This plane extends from the anterior aspect of the body to the posterior aspect. Motions in this plane, such as flexion and extension of the upper and lower extremities, rake place around a

FIGURE 1-3 The frontal plane, indicated by the shaded area, extends from one side of the body ro the other. Motions in this

plane, such as abduction and adduction of the upper and lowerextremities, take place around ananterior~posterior

axis.

medial-lateral axis!ion occurs in the transverse plane around a vertical axis (Fig. 1-4A and B). The vertical axis lies at right angles to motions such as circumduction (flexionabductionexten-

15

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the transverse plane and proceeds in a cranial to caudal direction. The morions described previously are considered to occur in a single plane around a single axis. Combination

sion-adducrion) are possible at many joints, but because of the limitations imposed by the uniaxial design of themeasuring instrument, only motions occurring in a single

plane are measured in goniometry. The rype of motion that is available at a joint varies

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Vertical axis

g. Id is m a (e Iy

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Vertical axis

fTransverse plane '

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FIGURE 14 (Aj The transverse plane is indicated by the shaded area. Movements in this plane take place around ;a vertical axis. These motions include rotation of the heaci(B),

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shoulder, (Aj, and hip;

well as pronation and,,~,~,p(nation of the forearm.' '

6

PA RT I

INTRODUCTION TO GONIOMETRY

according to the structure of the joint. Some joints, such as the interphalangeal joints of the digits; permit a large amount of motion in only one plane around a single axis: flexion and extension in the sagittal plane around a medial-lateral axis. A joint that allows motion in only one plane is described as having 1 degree of freedom of motion. The interphalangeal joints of the digits have 1 degree of freedom of motion. Other joints, such as the glenohumeral joint, permit motion in three planes around three axes: flexion and extension in the sagittal plane around a medial-lateral axis, abduction and adduction in the frontal plane around an anterior~posterior axis, and medial and lateral rotation in the transverse plane around a vertical axis. The glenohumeral joint has three degrees of freedom of motion. The planes and axes for each joint and joint motion to be measured are presented for the examiner in Chapters 4 through 13.

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Range of MotionB

Range of motion (ROM) is the arc of motion that occurs at a joint or a series of joints. ' The starting position for measuring all ROM, except rotations in the transverse plane, is the anatomical position. Three notation systems have been used to define ROM: the 0- ro 180-degree system, the 180- to O-degree system, and the 360-degree system. In the 0- to 180-degree notation system, the upper and lower extremity joints are at 0 degrees for flexionextension and abduction-adduction when the body is in anatomical position (Fig. 1-5A). A body position in which the extremity joints are halfway between medial (internal) and "lateral (external) rotation is 0 degrees for the ROM in rotation (Fig. 1-5B). An ROM normally begins at 0 degrees and proceeds in an arc toward 180 degrees. This 0- to 180-degree system of notation, also called the neutral zero method, is widely used throughout the world. First described by SilverJ in 1923, its use has been supported by many authorities, including Cave and Roberts; Moore," the American Academy of Orthopaedic Surgeons,'" and the American. Medical Association!

FIGURE 1-5 (A) In the anatomical position, the forearm is supinated so that the palms of the hands face anteriorly. (B) When the forearm is in a neurral position (with respect to rota-

tion), the palm of the hand faces the side of the body. measured (Fig. 1-{i). Documentation of extension ROM usually incorporates only the extension that occurs beyond the zero starting position. The term extension, as it is used in this manual, refers to both the motion that is a return from full flexion to the zero starting position and rhe morion that normally occurs beyond !he zero starting position. The term hyperextension is 'used to describe a greater than normal extension ROM. Two other systems of notation have been desctibed. The 180- to O-degree notation system defines anatomical position as 180 degrees. 1O An ROM begins at 180 degrees and proceeds in an arc toward 0 degrees. The 360-degree notation system also defines anatomical position as 180 degrees. ll l1 The motions of flexion and abduction begin at 180 degrees and proceed in an arc roward 0 degrees. The motions of extension and adduction begin at 180 degrees and proceed in an arc roward 360 degrees. These two notation systems are more difficult to interpret than the 0- to 180-degree notation system and are infrequently used. Therefore, we have not included them in this text.

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In the preceding example, the portion of the exrension ROM from full shoulder flexion back to rhe zero srarting position does not need to be measured because rhis ROM represents the same arc of motion that was measured in flexion. However, the portion of the extension ROM that is available beyond the zero starting position must be

Active Range of MotionActive range of motion is rhe arc of motion attained by a subject during unassisted voluntary joint motion. Having

CHAPTER 1

BASIC CONCEPTS

7

Passive Range of MotionPassive tange of motion is the arc of motion attained by an examinet without assistance from the subject. The subject remains relaxed and plays no active role in producing the motion. Normally passive ROM is slightly greater than active ROM 13.14 because each joint has a small amount of available motion that is not under voluntary control. The additional passive ROM that is available at the end of the normal active ROM is due to the strerch of tissues surrounding the joint and the reduced bulk of relaxed muscles. This additional passive ROM helps to protect joint structures because it allows the joint to absorb extrinsic forces . Testing passive ROM provides the examiner with information about the integrity of the articular surfaces and the extensibility of the joint capsule, associated ligaments, muscles, fascia, and skin. To focus on these issues, passive ROM rather rhan active ROM should be tesred in goniometry. Unlike active ROM, passive ROM does not depend on the subject's muscle strength and coordination. Comparisons between passive ROMs and active ROMs provide information abour rhe amount of motion permitted by the joint structure (passive ROM) relative to the subject's ability to produce motion at a joint (active ROM). In cases of impairment such as muscle weakness, passive ROMs and active ROMs may vary considerably.

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perform Joint mobiliry and JOint integrity tests on the subject can help determine which noncontractile structures are involved. Careful consideration of the end-feel and locaJion of tissue tension .and pain during passive ROM also adds information about structures that arc limiting ROM.

End-feelThe amount of passive ROM is determined by the unique structure of the joint being tested. Some joints arc structured so that the joint capsules limit the end of the ROM in a particular direction, whereas other joints are so structured that ligaments limit the end of a particular ROM. Other normal limitations to morion include passive tension in soft tissue such as muscles, fascia) and skin, 50ft tissue approximation, and contact of joint surfaces. The type of structure that limits a ROM has a c~arac teristic feel that may be detected by the examiner who is performing the passive ROM. This feeling, which is experienced by an examiner as a barrier to further motion ar the end of a passive ROM, is called the end-feel. Developing the ability to determine the character of the end-feel requires practice and sensitivity. Determinarion of the end-feel mUSt be carried out slowly and carefully to detect the end of the ROM and to distinguish among the various normal and abnormal end-feels. The ability to detect the end of the ROM is critical to theTABLE 1-2

safe and accurate performance of goniometry. The ability to distinguish among the various end-feels helps the examiner identify the type of limiting structure. Cyriax) IS Kaltenborn,16 and Paris 17 have described a variety of normal (physiological) and abnormal (pathological) endfeels I ' Table 1-1, which describes normal end-feels, "nd Table 1-2, which describes abnormal end-feels, have been adapted from the works of these amhors. In Chapters 4 through 13 we describe what we believe arc the normal end-feels and the structures that limit the ROM for each joint and motion. Because of the p311city of specific literature in this area, these descriptions ~lrC based on our experience in evaluating joint motion nnd on infornl;abdut"'W~~f[i/'Yif ~;K"?i.Ft~"tt'~V~>